产科学英文课件：5-heart-disease-pregnancy

HEARTDISEASEINPREGNANCYHEARTDISEASEINPREGNANCY1IntroductionTheincidenceofcardiaclesionislessthan1%amonghospitaldeliveries.Thecommonestcardiaclesionisofrheumaticoriginfollowedthecongenitalones.Inwesterncountriesmaternalheartdiseaseisnowthemajorcauseofmaternaldeathduringpregnancy[UK2003-2005].IntroductionTheincidenceofc2PhysiologicalchangesinpregnancyCOincreasesafter5wks,45%by24wks,decreasestonearnormalby10daysPPSV-increasesfrom8topeakat20wks,decreasestobaselineby2wksPPPl.volume-increasesby6wks,1.5-2timesnormalbyIItrimester,plateaus[TBWby6-8L,Naretension-500-900meq]IncreasedAorticcompliance,A-VshuntinginuterusPhysiologicalchangesinpregn3PregnancystressesthecardiovascularsystemWorseningknownheartdisorders;mildheartdisordersmayfirstbecomeevidentduringpregnancy.DecreasedHbandincreasedbloodvolume,strokevolume,andeventuallyheartrate.Cardiacoutputincreasesby30to50%.Thesechangesbecomemaximalbetween28and34wkgestationPregnancystressesthecardiov4PregnancystressesthecardiovascularsystemDuringlabor,cardiacoutputincreasesabout20%witheachuterinecontractionOtherstressesincludestrainingduringthe2ndstageoflaborandtheincreaseinvenousbloodreturningtotheheartfromthecontractinguterus

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CardiovascularstressesdonotreturntoprepregnancylevelsuntilseveralweeksafterdeliveryPregnancystressesthecardiov5EffectofheartdiseaseonfetusAbortionPretermdeliveryStillbirthFGRFetaldistressGeneticsEffectofheartdiseaseonfet6

Riskfactorsforcardiacfailureduringpregnancy

InfectionAnemiaObesityHypertensionHyperthyroidismMultiplepregnancy

Riskfactorsforcardiacfail7DiagnosisClinicalevaluationmilddyspnea

systolicmurmurs

jugularvenousdistention

tachycardia

dependentedema

mildcardiomegaly1Canbeenfoundinnormalpregnancyandheartdisorder.2DiastolicorpresystolicmurmursaremorespecificforheartdisordersDiagnosisClinicalevaluation8Howdoyougradethefunctionalcapacityofheart?Howdoyougradethefunctiona9Howdoyougradethefunctionalcapacityofheart?Howdoyougradethefunctiona10DiagnosisEKG:WhataretheECGchangesinpregnancy?1)LeadIIIoftenshowsaverydeepQwaveandinversionofTwave2)UnipolarleadsV2-V4mayshowflatteningofTwavewithdepressionofSTsegmentEchocardiographyX-rayDiagnosisEKG:WhataretheECG11EarlystageheartfailureChesttightness，palpitations,shortnessofbreathafterslightactivityHR〉110bpmand

respiratoryrate〉20perminatrestAtnight,oftensituporbreathefreshairbecauseofchesttightnessAsmallamountofpersistentmoistralesatthebottomoflungsandnotdisappearaftercoughEarlystageheartfailureChest12ThecontraindicationsforpregnancyPulmonaryhypertension(pulmonaryarterypressure>75percentsystemic)VentriculardysfunctionwithNewYorkHeartAssociation(NYHA)ClassIIItoIVheartfailuresymptomsEisenmenger’ssyndromeMarfansyndromewithaorticenlargement>40mmThecontraindicationsforpreg13ThecontraindicationsforpregnancySeverearrythmiasActiverheumaticfeverCombinedvalvulardiseaseBacterialendocarditissuperimposed

onheartdiseaseAcutemyocarditisThecontraindicationsforpreg14Perinatalcare

prenatalcare:aimtofindtheriskfactorsforheartfailure1onceevery2weeksbefore20weeksofgestationalage2onceeveryweekafter20weeksofgestationalagePerinatalcare

prenatalcare:15Perinatalcare

Whatshouldnothappenedduringantenatalperiod?A.ChangesincardiacoutputB.ChangesinthepulserateEg.Hypertension,anaemia,infectionPerinatalcare

Whatshouldnot16PerinatalcareDelivery

Timing:

1Inasymptomaticwomeningoodcondition—spontaneousdeliverycanbewaited.2Inwomenwithcomplexlesions,severecardiacdysfunction--aplanneddeliveryPerinatalcareDelivery17PerinatalcareDelivery

Modeofdelivery:

dependonobstetricindicationandthematernalhemodynamiccondition.AccordingtotheEuropeanguidelines,primaryCesareansectionshouldbeconsideredforthepatientswith1oralanticoagulants(OAC)inpretermlabor2severeheartfailure:VentriculardysfunctionwithNewYorkHeartAssociation(NYHA)ClassIIItoIVheartfailuresymptoms3aorticrootdiameter>45mm4acuteorchronicaorticdissectionPerinatalcareDelivery18PerinatalcareDeliveryVaginaldelivery:Firststageoflabor:

electrocardiogrammonitor

SedationantibioticsSecondstageoflabor:shortenthesecondstageoflabor:assistedvaginaldeliveryThirdstageoflabor:sandbagonabdomen,preventionofpostpartumhemorrhagePerinatalcareDelivery19PerinatalcareDeliveryVaginaldelivery:Whatshouldnothappeninlabour?A.PainB.ProlongedlabourC.MaternalexhaustionPerinatalcareDelivery20PerinatalcarePostpartum

electrocardiogrammonitor

Sedationantibioticscontrollvolumeofintravenousinfusionslowi.v.infusionofoxytocin(<2U/min),PGFanalogues[MethylergonovineC.I.[vasoconstriction&HTN]Elasticsupportstockings,andearlyambulation[reducetheriskofEmb]First12–24h[HF]hence,hemodynamicmonitoringcontinuedforatleast24hafterdelivery.

PerinatalcarePostpartum21PerinatalcarePostpartumLactationContraindication:VentriculardysfunctionwithNewYorkHeartAssociation(NYHA)ClassIIItoIVheartfailuresymptomsPerinatalcarePostpartum22Keypoints1Whatarethecontraindicationsforpregnancyinthewomenwithheartdisease?2Howtoselectthemodeofdeliveryforthepregnantwomencomplicatedbyheartdisease?3whatshouldbedoneinthelaborforthewomenwithheartdisease?4whataretheclinicalfeaturesofearlystageheartfailure?Keypoints1Whatarethecontr23HEARTDISEASEINPREGNANCYHEARTDISEASEINPREGNANCY24IntroductionTheincidenceofcardiaclesionislessthan1%amonghospitaldeliveries.Thecommonestcardiaclesionisofrheumaticoriginfollowedthecongenitalones.Inwesterncountriesmaternalheartdiseaseisnowthemajorcauseofmaternaldeathduringpregnancy[UK2003-2005].IntroductionTheincidenceofc25PhysiologicalchangesinpregnancyCOincreasesafter5wks,45%by24wks,decreasestonearnormalby10daysPPSV-increasesfrom8topeakat20wks,decreasestobaselineby2wksPPPl.volume-increasesby6wks,1.5-2timesnormalbyIItrimester,plateaus[TBWby6-8L,Naretension-500-900meq]IncreasedAorticcompliance,A-VshuntinginuterusPhysiologicalchangesinpregn26PregnancystressesthecardiovascularsystemWorseningknownheartdisorders;mildheartdisordersmayfirstbecomeevidentduringpregnancy.DecreasedHbandincreasedbloodvolume,strokevolume,andeventuallyheartrate.Cardiacoutputincreasesby30to50%.Thesechangesbecomemaximalbetween28and34wkgestationPregnancystressesthecardiov27PregnancystressesthecardiovascularsystemDuringlabor,cardiacoutputincreasesabout20%witheachuterinecontractionOtherstressesincludestrainingduringthe2ndstageoflaborandtheincreaseinvenousbloodreturningtotheheartfromthecontractinguterus

!!!

CardiovascularstressesdonotreturntoprepregnancylevelsuntilseveralweeksafterdeliveryPregnancystressesthecardiov28EffectofheartdiseaseonfetusAbortionPretermdeliveryStillbirthFGRFetaldistressGeneticsEffectofheartdiseaseonfet29

Riskfactorsforcardiacfailureduringpregnancy

InfectionAnemiaObesityHypertensionHyperthyroidismMultiplepregnancy

Riskfactorsforcardiacfail30DiagnosisClinicalevaluationmilddyspnea

systolicmurmurs

jugularvenousdistention

tachycardia

dependentedema

mildcardiomegaly1Canbeenfoundinnormalpregnancyandheartdisorder.2DiastolicorpresystolicmurmursaremorespecificforheartdisordersDiagnosisClinicalevaluation31Howdoyougradethefunctionalcapacityofheart?Howdoyougradethefunctiona32Howdoyougradethefunctionalcapacityofheart?Howdoyougradethefunctiona33DiagnosisEKG:WhataretheECGchangesinpregnancy?1)LeadIIIoftenshowsaverydeepQwaveandinversionofTwave2)UnipolarleadsV2-V4mayshowflatteningofTwavewithdepressionofSTsegmentEchocardiographyX-rayDiagnosisEKG:WhataretheECG34EarlystageheartfailureChesttightness，palpitations,shortnessofbreathafterslightactivityHR〉110bpmand

respiratoryrate〉20perminatrestAtnight,oftensituporbreathefreshairbecauseofchesttightnessAsmallamountofpersistentmoistralesatthebottomoflungsandnotdisappearaftercoughEarlystageheartfailureChest35ThecontraindicationsforpregnancyPulmonaryhypertension(pulmonaryarterypressure>75percentsystemic)VentriculardysfunctionwithNewYorkHeartAssociation(NYHA)ClassIIItoIVheartfailuresymptomsEisenmenger’ssyndromeMarfansyndromewithaorticenlargement>40mmThecontraindicationsforpreg36ThecontraindicationsforpregnancySeverearrythmiasActiverheumaticfeverCombinedvalvulardiseaseBacterialendocarditissuperimposed

onheartdiseaseAcutemyocarditisThecontraindicationsforpreg37Perinatalcare

prenatalcare:aimtofindtheriskfactorsforheartfailure1onceevery2weeksbefore20weeksofgestationalage2onceeveryweekafter20weeksofgestationalagePerinatalcare

prenatalcare:38Perinatalcare

Whatshouldnothappenedduringantenatalperiod?A.ChangesincardiacoutputB.ChangesinthepulserateEg.Hypertension,anaemia,infectionPerinatalcare

Whatshouldnot39PerinatalcareDelivery

Timing:

1Inasymptomaticwomeningoodcondition—spontaneousdeliverycanbewaited.2Inwomenwithcomplexlesions,severecardiacdysfunction--aplanneddeliveryPerinatalcareDelivery40PerinatalcareDelivery

Modeofdelivery:

dependonobstetricindicationandthematernalhemodynamiccondition.AccordingtotheEuropeanguidelines,primaryCesareansectionshouldbeconsideredforthepatientswith1oralanticoagulants(OAC)inpretermlabor2severeheartfailure:VentriculardysfunctionwithNewYorkHeartAssociation(NYHA)ClassIIItoIVheartfailuresymptoms3aorticrootdiameter>45mm4acuteorchronicaorticdissectionPerinatalcareDelivery41PerinatalcareDeliveryVaginaldelivery:Firststageoflabor:

electrocardiogrammonitor

SedationantibioticsSecondstageoflabor:shortenthesecondstageoflabor:assistedvaginaldeliveryThirdstageoflabor: